14 Big Changes in 'The Psychiatrist's Bible'

14 Big Changes in 'The Psychiatrist's Bible'

If you or a loved one has ever been treated for any mental health issue — from autism to addiction — you have one very thick book to thank for your diagnosis. Often called “the psychiatrist’s bible,” the Diagnostic and Statistical Manual of Mental Disorders, or DSM, is a reference tome published by the American Psychiatric Association. It identifies and classifies each mental disorder recognized by modern medicine, and is used in every corner of the mental heath industry, from psychiatrists’ couches to insurance company offices.

And like any good manual, it’s periodically in need of an update, which is currently under way. Here, get the details on the major changes to expect — including conditions being added, axed, or significantly amended.

DSM Revision Drama

DSM has undergone four main revisions since it was first published in 1952, taking flak along the way for using inconsistent science to define certain disorders and fueling social stigmas with diagnoses like mental retardation. A massive revision period for the newest edition, from DSM-IV to DSM-5, is currently under way. “Psychiatry continually looks at the available research to determine if there is new information that can better inform how clinicians diagnose patients,” says Darrel Regier, MD, vice-chair of the DSM-5 Task Force. “The changes in DSM-5 reflect a greater understanding of different mental disorders and how they relate to each other.”

As the revisions unfold, some conditions would be added or dropped altogether; others would be redefined or reclassified. Some would be moved or added to the main manual as official diagnoses, while others would join an appendix to be considered for further study. A public comment period on the proposed changes closed last month, and following a period of field trials and further review and revision, the completed DSM-5 is expected to be published in 2013. Here are the biggest and most controversial changes to expect.

AMENDED: Gender Identity Disorder

Gender identity disorder — defined by the current DSM-IV as having traits such as “strong and persistent cross-gender identification” — could be getting a whole new look in DSM-5. The condition would be renamed gender dysphoria — meaning a state of feeling unwell or unhappy about one’s gender — and include updated diagnostic criteria. The revisions are intended to address concerns of social stigma while still protecting insurance coverage. The proposed update is getting mixed reviews in the transgender community.

“We support the change of name,” says Lin Fraser, EdD, a San Francisco-based therapist and president-elect of the World Professional Association for Transgender Health (WPATH), which made recommendations to the DSM-5 task force on the revision. “WPATH believes that gender variance is not in and of itself pathological, and that having a cross-gender identity does not constitute a psychiatric ‘disorder.’” Others feel that no matter the name, a diagnosis that casts one’s identity as an illness should not be in the manual to begin with.

ADDED: Binge Eating Disorder

Surprisingly, binge eating disorder (BED) isn’t currently recognized as a formal diagnosis; DSM-IV only lists it in its appendix, meaning it is a condition proposed for further research. DSM-5 experts, however, recommend that the disorder be moved to the main manual, where it would join conditions such as anorexia nervosa and bulimia nervosa in the feeding and eating disorders category.

“In the almost 20 years since criteria for BED were included in an appendix in DSM-IV, approximately 1,000 articles on BED have been published in the scientific literature,” says B. Timothy Walsh, MD, chair of the DSM-5 Eating Disorders Work Group. All that research, he adds, has established that individuals with BED have abnormal eating behaviors and a higher rate of depression and anxiety. “These data support the potential benefit to such individuals of formally recognizing BED in DSM-5.”

AXED: Asperger's Syndrome

In one of the new edition’s biggest possible shake-ups, DSM-5 would recognize Asperger’s and autism along a singular continuum (from mild to severe) called autism spectrum disorders, rather than identifying Asperger’s syndrome — generally defined as a high-functioning form of autism — as a distinct diagnosis. “The proposed changes will improve the sensitivity and specificity of the criteria for autism spectrum disorders, so that clinicians may be able to more accurately diagnose these disorders,” says Dr. Regier. “This in turn may help researchers better understand these disorders so that effective treatments can be developed.”

But many criticize the proposed revision because high-functioning Asperger’s patients don’t want to be associated with severely withdrawn autism patients. “Putting all those people in the same soup isn’t helpful,” says Lynda Geller, PhD, a psychologist in private practice with New York-based Spectrum Services. “If you’re a college professor, your manifestations of autism spectrum symptoms are very different from those of a nonverbal child.” Geller adds that the threat of stigmatization could discourage people from seeking treatment. “I get calls now from people saying ‘I’ve heard about Asperger’s and that sounds like me,’ but no one calls to say ‘autism sounds like me’ — no one wants to think of themselves as having autism.”

AMENDED: Gambling Disorder

Gambling addictions may be getting a special spotlight in DSM-5. The new manual is re-organizing the category called Substance Use and Addictive Disorders to include both substance-based conditions (such as cocaine use) and behavioral conditions. But gambling disorder — characterized by indicators such as a preoccupation with gambling and a need to gamble with increasing amounts of money to achieve desired excitement — is the only behavioral addiction currently being considered for inclusion.

Other behavioral issues, such as sex (see next slide) and Internet addiction, are being proposed for the appendix; according to Regier, there isn’t enough research to support listing either behavior as an official diagnosis in the main manual.

“No longer will the word ‘addiction’ be associated only with substance use,” says Regier. “Research has shown that pathological gambling and substance use disorders are very similar in the way they affect the brain’s system of reward and aggression.” He hopes that recognizing compulsive gambling in the addictive disorders category “may help people get the help they need, and help others better understand the challenges patients face in overcoming this disorder.”

ADDED: Hypersexual Disorder

Find yourself continually shaking your head over the repeated sexual indiscretions of certain celebrities or politicians? There may be a newly named condition to describe such sexual overdrives. Hypersexual disorder, proposed for inclusion in DSM-5, would include traits such as “recurrent and intense sexual fantasies, sexual urges, and sexual behavior” that could cause “significant personal distress or impairment in social, occupational, or other important areas of functioning.” The DSM-5 Workgroup on Sexual and Gender Identity Disorders says hypersexual disorder is “one of the more serious but still neglected contemporary psychiatric disorders.”

Instead of being included in the main manual, however, where critics say hypersexual disorder should be added to the Substance Use and Addictive Disorders category, it’s slated for the appendix. “There is not enough research evidence from neuroscience and brain imaging to suggest this disorder is similarly associated with substance use disorders and gambling,” says Regier.

AXED: Hypochondriasis

This well-known term for obsessing over fears of serious illness could soon be defunct, because DSM-5 experts are proposing that hypochondriasis be split into two different disorders. The first would be the newly-created complex somatic symptom disorder (CSSD), which is characterized by excessive thoughts and feelings about legitimate physical symptoms, like pain. However, some patients previously diagnosed with hypochondriasis wouldn’t meet the criteria for CSSD because their excessive thoughts concern physical symptoms they don’t actually have (or experience only mildly); this group of soon-to-be-former hypochondriacs would be given the diagnosis of anxiety disorder.

ADDED: Disruptive Mood Dysregulation Disorder

The exploding number of children being diagnosed with bipolar disorder (a condition DSM-IV defines only for adults) has been the subject of much recent debate. In response to research that suggests many children are mislabeled as having bipolar disorder — characterized by unusual shifts in mood, energy and activity levels, according to the National Institute of Mental Health — because there isn’t a more accurate diagnosis available, DSM-5 is introducing a new youth-specific condition called disruptive mood dysregulation disorder. The criteria used to diagnose it would include traits such as “severe recurrent temper outbursts” that happen three or more times a week, accompanied by a persistently negative mood.

“Bipolar disorder doesn’t present the same way at all ages, and it’s difficult when criteria written for adults have to be applied to kids,” says Rebekah Horst Ganley, Psy.D., a psychologist with Pennsylvania Counseling Services in York, Pa. “I hope the new diagnosis would help both professionals and families realize that children aren’t mini-adults and need treatment that’s more geared toward them.”

ADDED: Premenstrual Dysphoric Disorder

For women whose time-of-the-month symptoms are much more serious than plain old PMS, DSM-5 is listening. premenstrual dysphoric disorder (PMDD), a severe form of premenstrual syndrome that was listed in the DSM-IV appendix, could now move to the main manual and be recognized as a formal diagnosis. The upgrade is hoped to result in better treatment for PMDD patients — which may include as many as two million U.S. women, according to the DSM-5 Mood Disorders Work Group — and to encourage more research on the condition.

While some critics question the disorder’s legitimacy, saying it pathologizes and stigmatizes a normal physical process, Regier points out that without the new diagnosis, women suffering from the condition could be misdiagnosed with labels such as mild depressive disorder. “This new diagnosis,” he says, “would describe a group of women whose symptoms are not well described by other psychiatric diagnoses currently listed in the manual, giving them a better opportunity to receive appropriate and reimbursable treatment.”

AXED: Histrionic Personality Disorder

Histrionic personality disorder (a dependence on others for self-worth) as it’s currently termed may be axed from DSM-5 along with other personality conditions such as schizoid personality disorder (indifference to others). The demise of these disorders is part of a broader revision to the entire personality disorders category, in which the very system of diagnosis could be drastically reorganized. “In the past we viewed personality disorders as binary: You either had one or you didn’t,” Regier explains. “Now we understand that personality pathology is more complicated than a yes/no approach and is more a matter ofsel degree.”

AXED: Mental Retardation

The much-maligned term mental retardation would be renamed intellectual developmental disorder, and the criteria used to define the condition would change to improve accuracy and clarity. Regier says that clarifying the diagnostic criteria could lead to earlier treatment.

In addition, "many patients and patient advocacy groups have expressed concerns about the stigmatizing nature of the term 'mental retardation,'" he says. "The proposed name change may facilitate better public awareness of and sensitivity to this diagnosis." Ganley agrees that the new name could have a positive impact. "If I have to tell someone their child is 'intellectually disabled,' that sounds a bit nicer than telling them their child is 'mentally retarded,'" she says. "It could be easier for a parent to hear."

ADDED: Hoarding Disorder

As far as DSM-IV was concerned, “the inability to discard worn-out or worthless objects” was one of many traits in its then-definition of obsessive-compulsive personality disorder. But DSM-5 proposes that hoarding be identified as its own stand-alone diagnosis; either in the main manual or an appendix for more research. The proposed diagnostic criteria should sound familiar to anyone who’s watched the A&E show Hoarders: they include characteristics such as “persistent difficulty discarding or parting with possessions” and “the accumulation of a large number of possessions that fill up and clutter active living areas.”

In its rationale for adding the disorder, the committee adds that hoarding “can lead to substantial distress and disability, as well as serious public health consequences that warrant consideration as a mental disorder.”

ADDED: Posttraumatic Stress Disorder in Preschoolers

A post-trauma-related condition isn’t one size fits all. Although DSM-IV uses one blanket PTSD diagnosis regardless of age, DSM-5 proposes branching off a subtype of PTSD specific to kids called post-traumatic stress disorder in preschool children. The update is meant to address new research into pediatric PTSD — and Ganley couldn’t be more excited about the revision.

“I treat a couple of preschoolers now who’ve experienced trauma and don’t meet the current criteria for PTSD, but they would meet the criteria for preschool PTSD,” she says. Ganley hopes the new diagnosis would help people realize that children experience the disorder differently than adults do, which could improve diagnosis and treatment. “It could help parents better understand what their child is going through,” she adds. “Sometimes when you give a name to something it helps parents realize their kid isn’t the only one with this problem.”

AMENDED: Stuttering

Amid the increased attention stuttering received in the wake of the 2010 film The King’s Speech, this verbal disorder is slated for an update. The condition is proposed to be renamed childhood onset fluency disorder in DSM-5, and its diagnostic criteria would undergo some tweaks. First, the use of interjections such as “uh’s” has been eliminated from the list of identifying traits because such fillers are used by “normal speakers.” In addition, “avoidance associated with speaking situations” is being introduced as a new characteristic of the disorder. The DSM-5 Work Group responsible for the proposal says the revisions are a result of “recent advances in knowledge of stuttering” and should “ensure that the millions of individuals who stutter will have greater access to comprehensive care including speech, cognitive, and emerging pharmacologic therapies.”

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